Piriformis Case Report

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journal of orthopaedic&sports physical therapy | volume 40 | number 2 | february 2010 | 103

[CASEREPORT]

Edwards14defines piriformis syndrome

as neuritis of branches of the sciatic nerve

caused by pressure of an injured or irri-

tated piriformis muscle. Symptoms asso-

ciated with piriformis syndrome typically

consist of buttock pain that radiates into

the hip, posterior aspect of the thigh, and

the proximal portion of the lower leg.28,29

In general, pain increases with sitting or

squatting, but persons with piriformis

syndrome may experience difficulty with

walking or other functional activities.12,29

Piriformis syndrome typically does not

result in neurological deficits such as de-

creased deep tendon reflexes and myoto-

mal weakness.29

Several authors attribute piriformis

syndrome to a shortening or spasm of

the piriformis that results in compression

of the sciatic nerve.6,10,15,27,29,33The cause of

spasm of the piriformis muscle has been

most attributed to direct trauma, postsur-

gical injury, lumbar and sacroiliac joint

pathologies, and overuse.

15-17,27,29

Givenas such, the standard treatment for piri-

formis syndrome has focused on decreas-

ing spasm or shortening of the piriformis

muscle and any associated inflamma-

tion. Medical management of piriformis

The piriformis originates from the anterior aspect of sacralvertebrae 2 through 4 and inserts on the greater trochanter.

The sciatic nerve typically exits the greater sciatic notchjust below the inferior border of the piriformis muscle.

In about 7% to 21% of studied populations, the sciatic nerve(or a division of it), actually penetrates the muscle.3,12,15,30,32,33

tSTUDY DESIGN:Case report.

tOBJECTIVE:To describe an alternative treat-

ment approach for piriformis syndrome using a

hip muscle strengthening program with movementreeducation.

tBACKGROUND:Interventions for piriformis

syndrome typically consist of stretching and/or

soft tissue massage to the piriformis muscle. The

premise underlying this approach is that a short-

ening or spasm of the piriformis is responsible

for the compression placed upon the sciatic nerve.

tCASE DESCRIPTION:The patient was a

30-year-old male with right buttock and posterior

thigh pain for 2 years. Clinical findings upon

examination included reproduction of symptoms

with palpation and stretching of the piriformis.

Movement analysis during a single-limb step-downrevealed excessive hip adduction and internal rota-

tion, which reproduced his symptoms. Strength

assessment revealed weakness of the right hip

abductor and external rotator muscles. The pa-

tients treatment was limited to hip-strengthening

exercises and movement reeducation to correct

the excessive hip adduction and internal rotation

during functional tasks.

tOUTCOMES:Following the intervention, thepatient reported 0/10 pain with all activities. The

initial Lower Extremity Functional Scale question-

naire score of 65/80 improved to 80/80. Lower

extremity kinematics for peak hip adduction and

internal rotation improved from 15.9 and 12.8 to

5.8 and 5.9, respectively, during a step-down task.

tDISCUSSION:This case highlights an alterna-

tive view of the pathomechanics of piriformis

syndrome (overstretching as opposed to over-

shortening) and illustrates the need for functional

movement analysis as part of the examination of

these patients.

tLEVEL OF EVIDENCE:Therapy, level 4.J Orthop Sports Phys Ther 2010;40(2):103-111.

doi:10.2519/jospt.2010.3108

tKEY WORDS:biomechanics, gluteus, hip pain,

radiculopathy, sciatica

1Physical Therapist, Department of Physical Medicine and Rehabilitation, Kaiser Permanente West Los Angeles, Los Angeles, CA. 2Physical Therapist, Department of Physical

Medicine and Rehabilitation, Kaiser Permanente Los Angeles, Los Angeles, CA. 3Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA.4Associate Professor and Co-Director, Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California,

Los Angeles, CA. Jason Tonley and Steven Yun completed this case report as a requirement for the Kaiser Permanente Los Angeles Movement Science Fellowship. Dr. Powers

acknowledges a financial interest in the SERF Strap that was used as part of this case report. Address correspondence to Dr Christopher M. Powers, Division of Biokinesiology

and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP-155, Los Angeles, CA 90089-9006. E-mail: [email protected]

JASON C. TONLEY, DPT, OCS Steven M. Yun, MPT, OCS RONALD J. KOCHEVAR,DPT, OCS

JEREMY A. DYE, MPT, OCS Shawn Farrokhi, PT, PhD, DPT ChriStopher M. powerS, PT, PhD4

Treatment of an Individual WithPiriformis Syndrome Focusing on HipMuscle Strengthening and Movement

Reeducation: A Case Report


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104 | february 2010 | volume 40 | number 2 | journal of orthopaedic &sports physical therapy

[CASEREPORT]

syndrome is reported in the literature to

include injections,1,3,5,8,11,15,16,26,27,30prescrip-

tion of nonsteroidal anti-inflammatory

drugs and muscle relaxants,1,5,8,11,15,16,26,27

surgical release,1,5,8,11,14,16 and referral tophysical therapy.1,5,11,15,20,27,30 The most

commonly reported physical therapy

interventions include ultrasound,1,5,11,16,19

soft tissue mobilization,1,5,11,15,16,19,30 piri-

formis stretching,1,11,15,16,19,26,27,30hot packs

or cold spray,5,11,15,16,19and various lumbar

spine treatments.1,5,8,10,13,26,30

As noted above, a common assumption

guiding physical therapy intervention for

piriformis syndrome is that the piriformis

is shortened or in spasm, creating com-

pression of the sciatic nerve. Our alter-nate theory is that the piriformis muscle

may be functioning in an elongated posi-

tion or subjected to high eccentric loads

during functional activities secondary to

weak agonist muscles. For example, if the

hip excessively adducts and internally ro-

tates during weight-bearing tasks due to

weakness of the gluteus maximus and/or

gluteus medius, a greater eccentric load

may be shifted to the piriformis muscle.

Perpetual loading of the piriformis mus-

cle through overlengthening and eccen-tric demand may result in sciatic nerve

compression or irritation.

Interestingly, many authors have rec-

ognized hip abductor weakness as an

associated finding with piriformis syn-

drome.1,2,3,5,8,13,17,27,32 Yet only 2 of these

reports included hip abduction strength-

ening as part of the treatment program,1,17

with 1 of the 2 authors noting that hip

abduction exercises seemed to hasten

recovery.17 Therefore, a treatment pro-

gram addressing hip strength and move-ment reeducation to control the femur in

the frontal and transverse planes during

functional activities may play a role in the

treatment of patients with piriformis syn-

drome who demonstrate excessive frontal

and transverse plane motions at the hip.

The purpose of this case report was

to describe an alternative treatment ap-

proach for piriformis syndrome that em-

phasizes hip muscle strengthening and

movement reeducation. The patient in

this case had symptoms consistent with

piriformis syndrome, weak hip abductors

and external rotators, and excessive hip

adduction and internal rotation during

functional lower extremity activities.

CASE DESCRIPTION

General Demographics

The patient was a 30-year-old

male who worked as a real estate

agent. He also reported that he was

a part-time tennis instructor and partici-

pated in a weekly basketball league. Apart

from his current symptoms, the patient

also had a 15-year history of intermittent

low back pain.

History of Presenting Condition

The patient was initially seen by an or-

thopaedic surgeon and given a diagno-

sis of sciatica. At this visit, radiographs

were obtained of his lumbar spine and

hip, which revealed no abnormalities.

The patient was subsequently referred to

physical therapy.

The patient presented to physical

therapy with a 2-year history of deep

right buttock pain that radiated to theposterior thigh. The patient stated that

the onset of his pain was insidious and

denied any trauma that contributed to his

current symptoms. The patient did not

report any prior treatment for his but-

tock and thigh pain, but stated that he

received intermittent chiropractic treat-

ment for his low back symptoms.

Presenting Complaints

The patient reported that his symptoms

were exaggerated by playing basketball ortennis for 30 to 60 minutes. Stairs and

squatting activities also were noted as

aggravating activities. He reported that

his pain was alleviated when he stopped

participating in sports, but that it would

be 4 to 6 days before symptoms would

completely resolve. The patients current

activity level included participation in a

weekly basketball league and teaching

tennis 6 to 12 hours per week. He report-

ed having to modify his tennis instruction

to avoid running activities. The patients

symptoms were limiting the number of

tennis lessons he could give per week

and his ability to play basketball. The pa-

tients stated goals were to participate inhis weekly basketball league and return

to his normal regime of tennis lessons of

3 nights per week for 2 to 4 hours.

Test and Measures

Pain and Functional Status The patient

completed a visual analog scale (VAS),

where 0 is no pain and 10 is the most pain

possible, to assess his current level of

pain.34The patients baseline pain in his

buttock and posterior thigh was 3/10 and

reached a level of 9/10 after participationin 1 game of basketball. Prior to treat-

ment, the patient completed the Lower

Extremity Functional Scale to evaluate

his functional status with regards to his

buttock and posterior thigh symptoms.

This self-assessment functional tool has

been shown to be valid and reliable.4The

patients score on the Lower Extrem-

ity Functional Scale Questionnaire was

65/80, with 80 representing maximum

function.

Differential Diagnosis Screening Activeand passive examination of the lumbar

spine and sacroiliac joint were performed

to rule out spine and pelvic contributions

to his symptoms. Active examination

tests for the lumbar spine consisted of ac-

tive range of motion (AROM), followed

by AROM with overpressure in flexion,

extension, and sidebending and rotation

to the left and right. Passive testing was

performed using both central and lateral

posterior-to-anterior spring tests from

the fifth lumbar to the tenth thoracic spi-nal segments. There was no reproduction

of his buttock or thigh symptoms with ac-

tive or passive testing to the lumbar spine.

The sacroiliac joint was assessed using a

cluster of tests, as described by Laslett.21

All tests were negative with respect to the

reproduction of symptoms.

Hip Joint Examination Passive mo-

tion assessment of the hip joint revealed

normal ranges for hip flexion, internal

rotation, and external rotation without


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reproduction of symptoms. Hip flexor

muscle length was assessed using the

Thomas test.18No restrictions were noted

when the 1-joint hip flexor was assessed

(ie, iliopsoas); however, restrictions(12) were evident when evaluating the

2-joint hip flexor (ie, rectus femoris).

Clinical tests were performed to as-

sess for intra-articular hip joint pathol-

ogy. The scour test, hip quadrant test, log

roll test, FABER, and active straight leg

test23were performed, and all were nega-

tive with respect to reproduction of the

patients symptoms. Clinical tests also

were performed to assess for piriformis

syndrome. These tests included the piri-

formis stretch test above and below 60of hip flexion,2,5,15,16 the flexion/adduc-

tion/internal rotation (FAIR) test,5,15,16

and piriformis contraction test.2 The

piriformis stretch test below 60 was

performed by maximally adducting and

internally rotating the hip, with the hip

flexed to 45. The piriformis stretch test

above 60 was performed by maximally

adducting and externally rotating the hip,

with the hip flexed to 90. The FAIR test

was performed by placing the patient in a

sidelying position on the unaffected side,with the affected (superior) hip being

moved passively into flexion, adduction,

and internal rotation.15,16The piriformis

contraction test was performed by plac-

ing the patient in the FAIR test position

and having the patient elevate the knee

off the table for 5 seconds.2The patient

was found to have reproduction of but-

tock and thigh symptoms with both of

the piriformis stretch tests, the FAIR test,

and the piriformis contraction test.

Neurodynamic testing, as described byButler,7was performed to assess the sci-

atic nerve. Reproduction of buttock pain

occurred at 50 of hip flexion during the

straight leg raise test. Assessment of the

straight leg raise test with ankle dorsi-

flexion resulted in reproduction of lower

back, buttock, and posterior thigh pain,

with only 10 of hip flexion. Symptoms

resolved with ankle plantar flexion.

Soft tissue palpation revealed tender-

ness of the piriformis muscle and tro-

chanteric bursa. Palpation also resulted

in the reproduction of buttock and pos-

terior thigh pain.Muscle Strength Manual muscle testing

of the hip musculature was performed

as described by Kendall et al.18 Hip ex-

tensor strength was tested in the modi-

fied position, due to hip flexor tightness.

Manual muscle test grades of 3+/5, 3+/5,

and 4/5 were given for the hip exten-

sors, hip abductors, and external rotators,

respectively.

Dynamic Assessment An observational

gait analysis was performed as the pa-

tient walked at a self-selected pace. The

patient demonstrated decreased hip ex-

tension bilaterally in terminal stance. Healso demonstrated abnormal movements

in both the frontal and transverse planes

during the stance phase on the right: (a)

right trunk lean during single-limb sup-

port, (b) increased hip adduction dur-

ing loading response through terminal

stance, (c) increased hip internal rotation

during weight acceptance through termi-

nal stance, and (d) contralateral pelvic

drop during single-limb support.

The patient also was evaluated while

FIGURE 1. Patient performing the step-down maneuver pretreatment (A) and posttreatment (B). Both photos were

taken at the same knee flexion angle (as assessed by motion analysis). Pretreatment, the patient demonstrates a

greater amount of hip internal rotation and adduction and contralateral hip drop.

FIGURE 2. The SERF Strap consist of a thin, elastic material that is secured to the proximal aspect of the leg,

wraps in a spiral fashion around the thigh, and is anchored around the pelvis. The line of action of the SERF Strap

pulls the hip into external rotation.


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[CASEREPORT]

performing a step-down maneuver, as

described by Souza and Powers.31 The

step-down task was selected because it

is a single-limb activity, thereby placing

greater demands on the lower-extrem-ity musculature. The step-down test in-

volved the patient stepping down slowly

from a 20.4-cm step using the affected

limb over a 2-second period. During this

test, the patient demonstrated a contral-

ateral pelvic drop, increased hip adduc-

tion, and increased hip internal rotation

(FIGURE 1A). The patient also reported an

increase in symptoms during this test

(7/10 on the VAS). The patient was then

provided verbal and visual instructions in

an attempt to correct the excessive hip ad-duction and internal rotation during the

step-down test. A repeated assessment of

the step-down test was then performed

without significant change in hip motion

or symptoms. A hip-strapping device

(SERF Strap; DonJoy Orthopedics Inc,

Vista, CA) was then applied to the pa-

tient to assist with hip control while per-

forming this maneuver. The SERF Strap

consists of a thin elastic material that

is secured to the proximal aspect of the

leg, wraps in a spiral fashion around thethigh, and is anchored around the pelvis

(FIGURE 2). The line of action of the SERF

Strap pulls the hip into external rotation,

with the intent of limiting excessive hip

adduction and internal rotation during

functional activities. The patient was ob-

served to have decreased hip adduction

and internal rotation, and reported de-

creased pain (4/10) when repeating the

step-down test with the SERF Strap. We

believe that the decrease in pain, com-

bined with improved hip kinematics,could be interpreted as a diagnostic indi-

cator that abnormal movement patterns

at the hip were a contributing factor to

his symptoms.

Biomechanical Evaluation

In additionto the clinical information ob-

tained during the physical examination,

the subject underwent a preinterven-

tion and postintervention biomechanical

evaluation at the Musculoskeletal Bio-

mechanics Research Laboratory at the

University of Southern California. The

purpose of this testing was to provide

objective data to compare the subjects

lower extremity kinematics before and

after the intervention.

Three-dimensional motion analysis

was performed using a computer-aided

video motion analysis system (Vicon, Ox-

ford, UK). Kinematic data were sampled

at 120 Hz. Reflective markers (14-mm

spheres) placed on specific anatomical

landmarks were used to determine lower

extremity joint motions in the sagittal,

frontal, and transverse planes. Data were

obtained while the patient performed the

10

15

20

0

5

Hip

Adduction

Angle

(deg)

0 20 40 60 80 100

10

15

20

0

5

Hip

InternalRotation

Angle

(deg)

0 20 40 60 80 100

5

Step-down Cycle (%)

Pretreatment Posttreatment

A

B

FIGURE 3. Comparison of (A) hip adduction and (B) hip internal rotation during the step-down maneuver

pretreatment and posttreatment.


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step-down maneuver. The subject was in-

structed to stand on his right lower ex-

tremity while performing a step-down in

2 seconds and to return to the starting

position in 2 seconds. The depth of thestep for the step-down maneuver was

set at 18 cm (approximately 10% of the

patients total body height). The speed of

the movement was guided with a metro-

nome set at 60 beats per minute. When

averaged across 5 repetitions, peak hip

adduction and internal rotation were

15.9 and 12.8, respectively (FIGURE 3).

These values were considered excessive,

based on the normative data previously

published by Souza and Powers.31

Assessment

Given the subjective and objective in-

formation obtained during our exami-

nation, it was our impression that the

patient demonstrated significant impair-

ments specific to the hip region. More

specifically, our patient presented with

weakness of the hip extensors, abductors,

and external rotators, limited control

of the hip and pelvis during functional

movement testing, and reproduction of

symptoms with passive stretching andactivation of the piriformis muscle. We

theorized that weakness of the gluteus

maximus and gluteus medius was con-

tributing to abnormal movement pat-

terns at the hip, thereby subjecting the

piriformis to excessive lengthening or

eccentric loading during functional ac-

tivities. In turn, we believed that the ex-

cessive lengthening of the piriformis was

compressing the sciatic nerve. The fact

that the application of the SERF Strap

resulted in a simultaneous improvementin hip motion and buttock pain sup-

ported our hypothesis. Therefore, it was

our belief that an intervention focused

on addressing the hip muscle weakness

and abnormal movement patterns would

alleviate the patients pain and improve

his functional status.

Intervention

Foundations for Treatment The patient

attended physical therapy 8 times over

a 3-month period. He was educated re-

garding his condition and the intended

treatment approach. In addition, realistic

goal setting was discussed.

The patients physical therapy pro-

gram focused on strengthening the hipabductors, extensors, and external rota-

tors, as well as movement reeducation.

Exercises were progressed over 3 phases.

The first phase consisted of nonweight-

bearing exercises to emphasize isolated

muscle recruitment. The second phase of

the program consisted of weight-bearing

exercises, and the third phase consisted

of dynamic and ballistic training (ie,

plyometrics). Throughout each stage,

the patient received feedback regarding

his movement pattern and was encour-aged to perform his exercises in a way

that would minimize lengthening of the

piriformis (ie, movement reeducation).

In particular, the patient was instructed

to minimize the amount of hip adduc-

tion and internal rotation during the

weight-bearing phase of his program.

This was accomplished using verbal and

tactile cueing.

When the patient could complete the

proposed exercises and repetitions in each

phase, the program would progress to the

next phase. The patient was given a home

exercise program that he was instructed

to perform once a day. The home exercise

program paralleled the exercises given inthe clinic. The patient was instructed to

perform all exercises in a manner that

would not reproduce his symptoms.

Phase 1: Isolated Muscle Recruitment

(Weeks 0-4) The patient was seen for 2

visits during this period. He was given 2

exercises: bilateral bridging to target his

hip extensors and sidelying clams to tar-

get his hip abductors and external rota-

tors. For all exercises during this phase

the patient was instructed to emphasize

motion at the hip joint and to avoid ex-cessive pelvis/trunk motion.

The bilateral bridge was performed

with Thera-Band wrapped around his

thighs just proximal to the knee (FIGURE

4A). The patient was instructed to elevate

his pelvis, while simultaneously abduct-

ing and externally rotating his hips. The

patient also was instructed to not allow

his thighs to adduct and internally rotate

while lowering the pelvis.

Initially, the sidelying clam exercise

was performed without resistance, withthe hip and knee in 45 of flexion with

his feet together (FIGURE 4B). The patient

was instructed to raise his knee up and

back, which was achieved through hip

abduction and external rotation. When

the patient was able to perform 3 sets

of 15 repetitions of the clam exercises

without resistance, the exercise was pro-

gressed by adding resistance with the use

of Thera-Band wrapped around the thigh

just proximal to the knee.

Phase 2: Weight-Bearing Strengthening(Weeks 4-9) The patient was seen for 3

visits during this phase of his rehabili-

tation. Initially, the patient began with

double-limb weight-bearing exercises

and was progressed to single-limb move-

ments to increase the demands on the hip

musculature.

At the third visit, the initial exercise

during this phase was a squat maneu-

ver with Thera-Band resistance applied

around the thighs just proximal to the

FIGURE 4. Phase 1 exercises included (A) bridge with

Thera-Band resistance, and (B) clam with Thera-

Band resistance.


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[CASEREPORT]

knees (FIGURE 5A). The patient was ini-

tially instructed to perform the squat to

a depth of 45 and then was progressed

to 75. The patient also was instructed

on a sidestepping exercise with Thera-

Band (FIGURE 5B). The patient started in

a squat position of 45 of hip and knee

flexion, and was instructed to take steps

to the right and left along a 10-m walk-

way by abducting and externally rotating

his hips. The patient was instructed to

maintain control of the hip in the fron-

tal and transverse planes (ie, knees over

toes), and to keep the trunk erect during

this exercise.At the fourth visit, single-limb sit-

to-stand and step-up/step-down exer-

cises were initiated. The single-limb

sit-to-stand exercise was performed in a

manner similar to the squat, in that the

patient was cued verbally to maintain

proper lower extremity alignment in the

frontal and transverse planes during the

exercise and to avoid trunk sidebending

(FIGURE 5C). The patient initially per-

formed the exercise from a 70-cm high

surface, as measured from the floor tothe top of a treatment table. Once he was

able to demonstrate adequate control of

hip motions in the frontal and trans-

verse planes for 3 sets of 15 repetitions,

the exercise was progressed by lowering

the surface in 4-cm increments to a final

height of 58 cm.

For the step-up/step-down exercise,

the patient used a 20-cm-high step

stool. He was instructed to perform the

step-down exercise by touching his heel

to the ground and returning slowly tothe start position over a 3-second pe-

riod (FIGURE 5D). Proper lower extrem-

ity alignment during the ascending and

descending portions of the movement

was monitored during each repetition.

Initially, he performed the exercise with

contralateral upper extremity support.

When he was able to demonstrate ad-

equate control of hip motions in the

frontal and transverse planes for 3 sets

of 15 repetitions, the exercise was pro-

gressed by removing the upper extrem-ity support.

Phase 3: Functional Training (Weeks

9-14) The patientwas seen for 3 visits

during this phase of his rehabilitation.

Progression to phase 3 took place when

he demonstrated adequate control of his

hip motions in the frontal and transverse

planes, for 3 sets of 15 repetitions, during

the phase 2 single-limb support exercises.

As part of phase 3, the patient performed

lunges at a 45 knee flexion angle to the

FIGURE 5. Phase 2 exercises included (A) squat with Thera-Band resistance, (B) side-step with Thera-Band

resistance, (C) single-limb sit to stand, and (D) step-down.

FIGURE 6. Phase 3 exercises included (A) forward lunge, (B) lunge at 45, (C) double-limb jump/lands position,

and (D) double-limb jump/single-limb land.


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left and right, double-limb vertical jumps

with double-limb landings, and double-

limb vertical jumps with single-limb

landings, alternating right and left sides.

Progression was achieved by perform-ing all exercise with an increased rate

of speed. This was done to replicate the

sport-specific demands the patient would

be placing on his lower extremity upon

discharge.

At the sixth visit, the patient initially

performed forward lunges (FIGURE 6A). In-

struction for this exercise included proper

alignment of the lower extremity (ie, not

to allow his knee to pass beyond his foot)

and to flex his lead knee to a depth of 75.

The patient was able to demonstrate ad-equate control of the femur in the frontal

and transverse planes for 3 sets of 15 rep-

etitions and was subsequently progressed

to lateral lunges at a 45 angle to the left

and right (FIGURE 6B).

At the seventh visit, the patient was

instructed to perform maximal effort

double-limb take-off jumps with double-

limb landings to a deep squat with 90

of knee flexion without hip adduction or

internal rotation (FIGURE 6C).

At the eighth visit, the patient demon-strated adequate control of his hip mo-

tions in the frontal and transverse planes

with double-limb take-offs and landings

for 3 sets of 15 repetitions and was pro-

gressed to maximal-effort double-limb

take-off jumps with right and left single-

limb landings (FIGURE 6D). The patient was

cued verbally to perform all single-limb

landings without excessive hip adduction

or internal rotation.

OUTCOMES

The patient was re-evaluated 14

weeks after the initiation of treat-

ment. All posttreatment assessments

were performed as described above.

Pain and Functional Status

The patient achieved a follow-up score of

80/80 on his Lower Extremity Functional

Scale questionnaire. He reported a 0/10

pain in his buttock and posterior thigh

during daily tasks, and while participat-

ing in his sporting activities. Subjectively,

the patient reported that he was able to

return to playing basketball and instruct-

ing tennis without limitation.

Hip Joint Examination

Re-evaluation of the patients hip dem-

onstrated no pain with the piriformis

muscle stretch tests, a negative FAIR

test, and no pain with soft tissue palpa-

tion. Reassessment of straight leg raise

was 50, with no reproduction of symp-

toms. Straight leg raise with dorsiflexion

was 40, with reproduction of symptoms

in the buttock region. As with the initial

evaluation, pain resolved with plantarflexion of the ankle.

Muscle Strength

Re-evaluation of hip muscle performance

revealed improved strength of the previ-

ously tested hip musculature. Postint-

ervention manual muscle test grades of

4+/5 were given to the hip extensors, ab-

ductors, and external rotators.

Dynamic Reassessment

Observational movement analysis re-vealed improved kinematics postint-

ervention. In general, decreases in

contralateral pelvic drop, hip adduction,

and hip internal rotation were noted dur-

ing the stance phase of gait. The patient

demonstrated similar improvements dur-

ing the step-down test (FIGURE 1B).

Biomechanical Reassessment

Postintervention biomechanical analysis

of the step-down test was performed as

described above. When compared to thepreintervention values, peak hip adduc-

tion improved from 15.9 to 5.8 and hip

internal rotation improved from 12.8 to

5.9 (FIGURE 3B).

Follow-up

The patient was contacted 1 year follow-

ing discharge to assess his functional sta-

tus. He reported that he remained pain

free and continued to participate in all

physical activities including his weekly

basketball league and tennis instruc-

tion without limitation. The patient was

asked to complete a follow-up Lower

Extremity Functional Scale in which he

scored 80/80.

DISCUSSION

The purpose of this case report

was to describe an alternative

treatment approach for piriformis

syndrome, focusing on hip muscle

strengthening and movement reeduca-

tion. Previous clinical reports address-

ing piriformis syndrome have focused

on multiple, concurrent treatment

interventions and have emphasizedstretching,1,11,15,16,19,26,27,30 soft tissue mo-

bil ization, 1,5,11,15,16,19,30 electrophysical

agents,1,5,11,16,19 and medication and in-

jections.1,3,5,8,11,15,16,26,27,30 The overriding

premise behind such interventions is

that a shortened piriformis is respon-

sible for creating compression on the

sciatic nerve.5,9,11,15,27,29,33 Although 2

previous authors addressed hip abduc-

tor weakness and 1 author noted that

hip abductor strengthening seemed

to hasten recovery,1,17

these authors of-fered no mechanism as to why strength-

ening would be effective. After a review

of the published literature, no studies

were found that mentioned our pro-

posed mechanism of injury or treatment

approach.

The current case report suggests

that piriformis syndrome can be man-

aged without stretching, electrophysi-

cal agents, or soft tissue mobilization.

Given that the piriformis attaches to the

greater trochanter, we hypothesized thatthe excessive motions of hip adduction

and internal rotation observed during

functional movement tests were putting

strain on this muscle resulting in com-

pression of the sciatic nerve. Following

this line of thought, we believed that if

the abnormal movement patterns could

be corrected by strengthening of the hip/

pelvic musculature along with movement

reeducation, strain on the piriformis

could be minimized, resulting in less


8/9


9/9


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Piriformis Case Report